NCLEX basic care and comfort Actual Questions and Answers 2024 with complete solution

NCLEX basic care and comfort Actual Questions and Answers 2024 with complete solution A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority? - Answer ️️ -Assist the client with feeding. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? - Answer ️️ -keeping extraneous noise to a minimum; A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? - Answer ️️ -Use a pulse oximeter to determine oxygen saturation. The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse take next when continuing efforts to promote comfort? - Answer ️️ -Increase the client's confidence in the nurse. A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain? - Answer ️️ -FACES Pain Rating Scale; The nurse should use the FACES pain rating scale for children age 3 or older. The visual analog and numerical scales are used preferred with adults or older children who count well. The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate for very small children or nonverbal children. A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply. - Answer ️️ - apple juice broth tea; A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room temperature. A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil? - Answer ️️ -Tea tree oil has antibacterial properties; Tea tree oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns, insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the client and also call the prescriber to report the tea tree oil application on the surgical site. A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request? - Answer ️️ -Use the Faces Pain Scale to assess the child's degree of pain. The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? - Answer ️️ - The student nurse irrigates the NG tube through the blue air vent port; The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it. When assessing a child for impetigo, the nurse expects which assessment findings? - Answer ️️ -honey-colored, crusted lesions For a client with anorexia nervosa, which goal takes the highest priority? - Answer ️️ -The client will establish adequate daily nutritional intake. A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position? - Answer ️️ -left lateral; The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch? - Answer ️️ -